Job Title: Registered Nurse
Location: Aguadilla, Puerto Rico
Puerto Rico Registered Nurse License
In this role, you will be responsible for accurate and timely processing of healthcare claim service request and processing of claims using your medical knowledge to process according to a workflow that requires the review and evaluation of the service request as per SOP.
Job responsibilities:
- Responsible for accurate and timely processing of healthcare claim service request and processing claims
- Reviews, evaluates the service request as per SOP
- Familiar with Medical Policy, Familiar with Clinical service requests, correspondence inquiries and image review
- Forward the cases to appropriate teams, post the in-scope activities have been completed as per SOP (Standard operating Procedure)
- Prep medical records for clinical review
- End to end processing and resolution of clinical claims and correspondence
- Understand/interpret medical terminology including clinical notes and reports
- Able to review medical policies and determine the appropriate claim processing or clinical review process decisions (pay, request additional records, refer for clinical review)
- Review and determine pricing for clinical claims in accordance with negotiated pricing agreements
- Adept knowledge of verifying member benefits, eligibility verification and medical necessity determination
- To apply clinical judgement in lines of applicable guidelines while they provide post service Medical Necessity Determination (MND) reviews for Claim Policy business area led by reputed US Payer organization/s
- To work in collaboration with Medical Directors to deliver top quality medical necessity determination services to clients
Basic Qualifications
- High School Diploma or GED Equivalent
- At least 2 years of experience relating to the job description
Preferred Qualifications
- Current Puerto Rico Registered Nurse valid license
- Intermediate to advanced knowledge in using MS Office and ability to learn and use various computer software
- Past experience in an office/clerical setting in the medical field
- Experience in any claim adjudication platform
- Certification in medical coding (CPT, ICD-10
- Exposure to Healthcare Claims products (Indemnity, PPO, POS/DA, EPO, HMO)
- Prefer knowledge of Workman's Compensation, Medicare, COB, no fault
- Prior claims experience in medical coding, case management, cost containment review, medical claim management will be preferred
Note: Applicants for employment in the U.S. must possess work authorization which does not require sponsorship by the employer for a visa (H1B or otherwise).
The job entails sitting as well as working at a computer for extended periods of time. Should be able to communicate by telephone, email or face to face.
Work Model:
This role is onsite 5 days per week in the office in Aguadilla.
Job Type: Full-time
Benefits:
- Dental insurance
- Health insurance
- Life insurance
- Vision insurance
Experience:
- Nursing: 2 years (Required)
Work Location: In person
